Performativity, identity formation and professionalism: Ethnographic research to explore student experiences of clinical simulation training

Developing professional identity is a vital part of health professionals’ education. In Auckland four tertiary institutions have partnered to run an interprofessional simulation training course called Urgent and Immediate Patient Care Week (UIPCW) which is compulsory for Year Five medical, Year Four pharmacy, Year Three paramedicine and Year Three nursing students. We sought to understand student experiences of UIPCW and how those experiences informed student ideas about professional identity and their emergent practice as health professionals within multidisciplinary teams. In 2018, we commenced ethnographic research involving participant observation, field notes, interviews, photography and observational ethnographic film. A total of 115 students participated in this research. The emergent findings concern the potentially transformative learning opportunity presented within high fidelity multi-disciplinary simulations for students to develop their professional identity in relation to peers from other professions. Our work also exposes the heightened anxiety and stress which can be experienced by students in such interdisciplinary simulations. Student experience suggests this is due to a range of factors including students having to perform in front of peers and staff in such simulation scenarios when their own professional identity and capabilities are still in emergent stages. Staff-led simulation debriefs form a critical success factor for transformative learning to be able to occur in any such simulations so that students can reflect on, and move beyond, the emotion and uncertainty of such experiences to develop future-focused concepts of professional identity and strategies to support effective interprofessional teamwork.


Abstract:
Developing professional identity is a vital part of health professionals' education. In Auckland four tertiary institutions have partnered to run an interprofessional simulation training course called Urgent and Immediate Patient Care Week (UIPCW) which is compulsory for Year Five medical, Year Four pharmacy, Year Three paramedicine and Year Three nursing students. We sought to understand student experiences of UIPCW and how those experiences informed student ideas about professional identity and their emergent practice as health professionals within multidisciplinary teams. In 2018, we commenced ethnographic research involving participant observation, field notes, interviews, photography and observational ethnographic film. A total of 115 students participated in this research. The emergent findings concern the potentially transformative learning opportunity presented within high fidelity multi-disciplinary simulations for students to develop their professional identity in relation to peers from other professions. Our work also exposes the heightened anxiety and stress which can be experienced by students in such interdisciplinary simulations. Student experience suggests this is due to a range of factors including students having to perform in front of peers and staff in such simulation scenarios when their own professional identity and capabilities are still in emergent stages. Staff-led simulation debriefs form a critical success factor for transformative learning to be able to occur in any such simulations so that students can reflect on, and move beyond, the emotion and uncertainty of such experiences to develop future-focused concepts of professional identity and strategies to support effective interprofessional teamwork.
Jennifer M Weller      The present study was conducted to identify whether we were missing any important aspects   teamwork alongside other students and faculty from a range of specialties and disciplines.

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They are encouraged to reflect on their own performance within their own scope of practice, 175 and in relation to other health professionals' scopes of practice.   The aspect of performance that seems to be barely accounted for in health professions 239 education literature is that of performance as acting and presenting particular aspects of the 240 self in an intentional and practised way; i.e. as performativity (27-29). In this paper we look 241 closely at performativity as intrinsic to the student experience. performance is also acting and presenting particular aspects of the self in an intentional and 248 practiced way; as performativity. Performativity is the convergence of a dynamic set of forces 249 that play out in performances. In contrast to performance as an evaluative process, 250 performativity not only looks to the end productcompetencebut also explores language, 251 structure, behaviours and context to elicit meaning during the process of performing.

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Performativity includes both theatrical components (actions students take because they 253 perceive an expectation that they do so) and improvisational components. As Sommerfeldt 254 argues, the "performative aspect of healthcare teams contributes to cultural rituals comprising 255 language (jargon), masks (name tags, white coats, uniforms), and performances on cue that   (Table 1). Eighty-three staff 287 were invited to participate and of these 78 consented (94% consent rate).   The first simulation was scheduled to begin after morning tea break on day one. During the 312 break students separated from their assigned interprofessional groups and joined peers from 313 their own professions. There was a general feeling of tension and they almost unanimously 314 reported feeling "nervous". They were nervous about the upcoming simulation scenario; how 315 they would perform, whether they would make mistakes or have a stress-induced "mind 316 blank", and what their observing peers would think of them if they performed badly. Some 317 students said they experienced sweating, increased anxiety and in two cases an urgent need to 318 use the bathroom. Students desired to perform, and be seen as performing, appropriately 319 within the disciplinary boundaries of their profession specifically, and of healthcare more 320 broadly.

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At the beginning of the first simulation, students were separated into two sub-groups: the 322 observers and the simulation scenario. Observers watched from behind one-way glass in an 323 observation room while the others waited in the hall for staff to signal them to enter the 324 simulation room (Figures 1-3). Once they entered the room students could not see their 325 observers but they knew they were being watchedcloselyand by several people.  Following the simulation, all students from the group sat in a circle in the debrief room joined 337 by two or three teaching staff. First, students reported their feelings. The most frequent 338 reactions described were "nervous", "overwhelmed", "anxious", "uncertain" and "flustered." identity revolving around a clear sense of patient-centred focus. In general, the medical 378 students appeared to struggle more than other disciplinary groups to communicate 379 compassionately with 'patients.' One nervous student, for instance, told the patient that they 380 had suffered a heart attack and followed this cheerfully with "you are in the best place for it."

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Their intention was to provide reassurance but the patient was not reassured. In another 382 simulation a medical student spoke with a palliative patient whose voice became weak and 383 quiet. The student was standing at the end of the bed. He gradually increased his volume as 384 he spoke and gestured for the patient to speak louder (which the patient did not do). During 385 the debrief the group discussed whether moving closer to the patient might have been a more 386 effective strategy to demonstrate compassion and promote effective communication.

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Responding to professional uncertainty: confidence and anxiety 389 Some students' observed actions (or lack of actions) within the simulations can be understood 390 as a response to their less solidly formed identity and/or their less developed experience in 391 applying their emerging professional capabilities. Paramedicine students, for example, had 392 experienced considerably more simulation training than their peers had prior to the UIPCW 393 simulation course. Not surprisingly, paramedicine students were more confident and vocal 394 about their abilities than other students. This confidence is an indicator that they were more 395 familiar with the routines, requirements, and skills associated with a successful 'performance' 396 and therefore, did not experience anxiety as often as other students. When reflecting on their 397 performance in simulations paramedicine students said to each other, "we are quite good at 398 communicating", "we even involve family members" and "we advocate for our patients."

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Their confidence was evident during simulations, and also shone throughout classroom-based 400 activities where they sat more up-right and engaged in whole class discussions more than 401 their peers did. Medical students noticed the confidence and capability of paramedicine 402 students in simulations. On many occasions students made reference to the confidence and 403 competence of paramedicine students to make a case for greater and earlier inclusion of 404 simulation training in their own curriculum.

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The flipside to student personal and shared confidence, is their perceptions of, and responses 406 to, the personal uncertainty about how to perform adequately, worries about missing 407 something obvious, failing to correctly diagnose and treat the simulated patient, or appearing 408 unprofessional. When asked what their biggest concerns were, medical students responded 409 with such comments as "that I might make a mistake but it's a good environment to learn in."

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How students respond to uncertainty is informed by their prior experience. In this case, with 411 prior experience of simulation training, of working with students from other professions, and 412 of caring for patients. Responding to uncertainty has elsewhere been discussed in terms of perceptions of risk and responses to it (31, 34-37). We suggest that prior student experiences 414 and their disciplineas social statusalso significantly informed their uncertainty 415 (perceptions of risk) and confidence. This also influenced the discourse they projected and 416 promoted amongst their (inter-) professional peers.  The authors thank all students and staff who participated in this study.

Box 1. Urgent and Immediate Patient Care Weekprior research
Medical: One year after experiencing UIPCW, when medical students became Trainee Interns (first year of clinical practice internship), students who had participated in the training were twice as likely to take an active role in ward calls than peers who had not attended the training (1). Student evaluations showed that medical students valued learning about the scopes of practice of nurses and pharmacists in terms of leadership, roles, and responsibilities.
Pharmacy: In a further study (7), pharmacy student evaluations suggested that their key learning areas were prioritisation of care, systematic assessment of patients, appreciating scopes of practice and communication strategies.
Nursing: Nursing student evaluations (unpublished) suggested they had developed effective ways to share information with other members of the care team in a timely fashion. These different foci of students from the various disciplinary groups reflected, to a large extent, their professional roles and responsibilities within urgent and immediate patient care. In the workplace, for example, nurses are often first on the scene when a patient deteriorates. Thus, nurses in UIPCW were encouraged to focus on serial assessment and management of the patient, including hand over of relevant information to other members of the healthcare team.  Across the four days the focus shifts from community care (day 1) to palliative care (day 2) and acute inpatient care (days 3-4). Medical students are present on all four days while pharmacy students are present for days one, two, and four. Paramedic students are only present for the first two days, and nursing students are present for the final two days. Students are allocated to interprofessional groups of 8-12 students. Groups are maintained throughout the four-day course. Groups rotate between interactive classroom-based activities and simulated scenarios.

Simulation training
A smaller mixed professional team of students (with at least one from each profession present) participates in each simulation; all students are involved in at least one scenario and otherwise observe their peers. Structured debriefs follow each simulation to explore reactions, 'unpicking' actual events with a focus on how learning transfers to the real work-place. Facilitators strive to cultivate a safe and positive atmosphere during debriefing with emphasis on transfer of learning of future-focused principles and practices.